Life Care Center Of South Las Vegas
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, Nevada.
- Location
- 2325 E. Harmon Ave., Las Vegas, Nevada 89119
- CMS Provider Number
- 295076
- Inspections on file
- 27
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Life Care Center Of South Las Vegas during CMS and state inspections, most recent first.
A resident with cellulitis, polyneuropathy, and multiple lower-extremity wounds was discharged home with orders for home health OT, PT, and nursing for wound care, as well as a recommended two-wheeled walker, but the facility did not ensure that a home health agency had accepted the referral or that DME was arranged before discharge. Social services staff acknowledged that referrals for home health and DME were denied due to insurance network issues and that the facility’s practice was to discharge without waiting for acceptance, later advising residents to follow up with their PCP. After discharge, the resident reported having no walker, no home health contact, and unchanged wound dressings from the day of discharge, while the record lacked documentation of any discussion with the resident about the lack of home health acceptance or refusal to remain under private pay, despite a policy requiring discharge plans to meet health and safety needs and preferences.
The facility failed to provide and document scheduled showers for three residents who required assistance with bathing. A resident with mobility limitations and intact cognition, scheduled for twice-weekly showers, reported receiving only two showers and denied ever receiving bed baths or refusing one of the showers, despite documentation to the contrary. Another cognitively intact resident, also scheduled for twice-weekly showers, missed a scheduled shower with no documentation of refusal or re-offer. A third resident with moderately impaired cognition and total dependence on staff for showers reported not receiving a shower during a two-week stay, and records showed two missed scheduled showers, one related to a room change and another without a documented reason, with only a single bed bath recorded. Facility policy required residents to receive a full shower or bath at least twice weekly according to their needs and preferences.
A resident with hemiplegia and hemiparesis following a cerebral infarction had a physician order for a CT scan to rule out an ascending aortic aneurysm, but the exam was never completed. The Unit Manager entered the CT order into the medical record but did not complete the required appointment request form, so case management was not notified to schedule the test with an outside provider. The DON confirmed this missed CT scan was an oversight, contrary to the facility’s diagnostic services policy requiring timely coordination and completion of ordered diagnostic services.
The facility failed to secure medications in a central supply room, which was found propped open and accessible. Two unlocked medication carts containing various medications and supplements were observed. Staff confirmed the room should have been locked to prevent unauthorized access, as per facility policy.
A facility failed to document a nutritional assessment and food preferences for a resident admitted with lupus and mild kidney injury. Despite a physician's order for a regular diet, there was no record of food preferences. The Dietary Director indicated that dietary staff should document preferences within 24 hours, but this was not done. The facility's policy required a visit within 72 hours to obtain preferences and complete the nutrition assessment.
A resident with dementia and a history of cholecystectomy experienced a fall, and the facility failed to implement a comprehensive care plan for fall management. Although a physical therapy consultation was suggested, it was not conducted, and the necessary screening and evaluation were delayed for seven weeks, contrary to the facility's policy.
A facility failed to provide scheduled showers to dependent residents, affecting three individuals with conditions such as dementia and hemiplegia. Despite care plans indicating the need for substantial assistance with bathing, there was no documentation of completed showers or refusals on scheduled dates. The facility's policy required assistance for activities of daily living, but this was not adhered to, resulting in a deficiency in hygiene care.
A resident was admitted with a urinary catheter without sufficient medical justification, as the diagnosis of benign prostatic hyperplasia (BPH) alone was not adequate for catheter placement. The resident's medical record lacked documentation of a bladder training program or justification for the catheter's use. The DON acknowledged the deficiency, noting that the facility's policy required a determined need and medical indication for catheter use, which was not met in this case.
A facility failed to follow a physician-ordered fluid restriction for a dialysis-dependent resident with end-stage renal disease and cardiac conditions. Despite a prescribed limit of 1000 ml per day, the resident had access to excess fluids, including a full water pitcher and other beverages. Staff were unaware of the restriction, and the care plan did not reflect it, leading to a lack of monitoring and documentation of fluid intake. The facility's policies required adherence to such orders, but these were not followed, posing a risk of fluid overload.
A facility failed to account for narcotics signed out for a resident, risking delayed pain management. The resident had a prescription for Hydrocodone-Acetaminophen, but the narcotic log was missing for several months, and discrepancies were found between the log and the MAR. Staff interviews revealed that the expected procedure was not followed, leading to the deficiency.
A resident with end-stage renal disease and dependence on dialysis continued to receive Spironolactone, a contraindicated medication, despite a pharmacist's recommendation and physician's agreement to discontinue it. The medication administration record showed the medication was still active, and an LPN confirmed its administration. The DON explained the process for medication review, but the order was not discontinued, indicating a failure in the facility's process.
A facility failed to maintain a medication error rate below five percent, with an observed rate of 7.41%. During a medication pass, an LPN administered incorrect dosages to a resident with chronic kidney disease and neuropathy, failing to give the prescribed amount of Gabapentin and omitting Oxybutynin, despite it being documented as given. The DON confirmed the expectation for nurses to verify medication orders and adhere to the five rights of medication administration.
The facility failed to properly label and date stored foods, and did not adhere to appropriate storage practices, posing potential health risks. Observations revealed unlabeled and undated food items in the freezer and cooler, and employee drinks stored improperly. The facility's Food Safety guidelines were not followed.
The facility failed to ensure a safe discharge for two residents, leading to potential placement in inappropriate settings without necessary care. For one resident, there was no documentation of group home evaluation or family agreement, and key staff were uninvolved. Similarly, the second resident's discharge lacked documentation of family involvement and group home details, with key staff again uninvolved.
Failure to Secure Home Health and DME Prior to Discharge for Resident With Wound Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge, including home health services and DME, was fully arranged and accepted prior to discharge, despite the resident’s need for ongoing wound care and assistive devices. The resident was admitted with cellulitis of the right lower limb and polyneuropathy and had chronic wounds on both lower extremities requiring specific dressing changes. A physician’s order authorized discharge home with current medications, required staff to provide medication education, and ordered home health services including OT, PT, and nursing for wound care evaluation and treatment, with detailed instructions for cleansing and dressing multiple wounds. A NOMNC was completed and signed with a specified service end date, and the discharge summary documented that the resident left with medications, belongings, and education on medications, accompanied by a family member. Interviews and record review showed that the facility’s discharge planning process did not ensure that a home health agency had accepted the referral before the resident left. The Social Services Director stated that case managers should verify acceptance of home health prior to discharge, but a Social Services Assistant (SSA) reported that the facility did not wait for home health acceptance and, if a resident was not accepted, the facility would later contact the resident and advise them to follow up with their PCP. The SSA further explained that on the day of discharge they received notification that the referral for home health and DME was not accepted due to insurance network issues, and that there was confusion between the insurance unit authorizing the facility stay and the unit responsible for home health, resulting in denials as out-of-network. The SSA acknowledged that best practice would have been to wait until a home health agency had accepted the resident before discharging and noted that the resident had been authorized for the facility stay and required discharge by the insurer. After discharge, the resident reported not receiving any DME, including a walker that had been expected, and no home health visits or contact. As of a later interview date, the resident still had wound dressings in place from the day of discharge and had not had a full shower due to concern about wetting the bandages. The resident stated that no one from the facility had called to check on their welfare or whether DME or home health had been provided, and that they were ambulating at home without a walker, holding onto walls and furniture. The insurance company informed the resident that any DME and home health services needed to be arranged through approved vendors and that such needs should have been addressed during IDT meetings. A PT discharge summary documented that home health services and a two-wheeled walker were recommended, and the wound care nurse stated that the resident should have been followed by an outpatient wound care provider and that complications could occur from missed dressing changes. The DON and SSA characterized the discharge as insurance-driven and stated that the resident was informed of private-pay options and expressed a desire to go home with wound services; however, the medical record lacked documentation of any conversation about the lack of home health acceptance or any documented refusal by the resident to remain at the facility under private pay. The facility’s discharge planning policy required that the discharge destination meet the resident’s health and safety needs and preferences, but the documented process and interviews showed that the resident was discharged without confirmed home health acceptance and without ensured provision of ordered wound care and DME.
Failure to Provide Scheduled Showers and Accurately Document Bathing Care
Penalty
Summary
The facility failed to ensure scheduled showers were provided for residents assessed as needing assistance with bathing, resulting in missed or undocumented showers for three of five sampled residents. One resident with intact cognition and mobility limitations requiring substantial/maximal assistance for bathing reported being told they were scheduled for showers twice weekly and stated they had only received two showers since admission. The shower schedule and ADL bathing documentation showed two showers on specific dates, refusals documented on two other dates, and several bed baths recorded; however, the resident denied ever receiving bed baths and denied refusing one of the documented showers. During an interview, the resident reiterated a strong preference for showers over bed baths and stated they would not refuse a shower, and the DON acknowledged that the resident’s account did not align with the medical record. Another cognitively intact resident requiring partial/moderate assistance with bathing reported missing showers. Review of the shower schedule and ADL bathing report showed this resident was scheduled for showers twice weekly but missed a scheduled shower with no documentation of refusal or re-offer, which the DON confirmed. A third resident with moderately impaired cognition and total dependence on staff for showers reported being in the facility for two weeks without receiving a shower. The shower schedule and ADL bathing report revealed this resident missed two scheduled showers, one associated with a room change and another with no documented reason, with only one bed bath documented between the missed showers. The facility’s ADL Service Assistance policy required that residents receive a full shower or bath according to their needs and preferences at least twice per week.
Failure to Complete Ordered CT Scan Due to Missed Scheduling Process
Penalty
Summary
The facility failed to carry out a physician order for a CT scan for one resident. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. A physician order dated 12/10/2026 directed that the resident receive a CT scan to exclude an ascending aortic aneurysm. Review of the medical record showed no documented evidence that the CT scan was ever completed for this resident. The Unit Manager stated that certain diagnostic procedures, such as X-rays, KUB, and EKG, could be done in the facility, while CT scans, MRI, and barium swallow tests had to be scheduled with an outside provider. The Unit Manager explained that after a physician order for a CT scan is obtained, a nurse is supposed to complete an appointment request form and give it to case management to schedule the procedure. The Unit Manager acknowledged personally entering the CT scan order into the medical record but forgetting to complete the appointment request form, so the order was never communicated to case management. The DON confirmed that the missed CT scan was an oversight. The facility’s Diagnostic Services policy stated the facility would ensure diagnostic services meet residents’ needs and that the facility would be responsible for the quality and timeliness of services, whether provided on-site or by an outside resource, with results reported timely to the ordering physician.
Unsecured Medication Storage in Central Supply Room
Penalty
Summary
The facility failed to ensure the security of medications in one of its central supply rooms, which was observed to be unsecured. On the specified date, the central supply room door was found propped open with a dumbbell, allowing unauthorized access. Inside the room, two medication carts were found unlocked, with keys hanging from one of the cart locks. The carts contained various medications and nutritional supplements, including Vitamin C, Benadryl, Omeprazole, and Nexium, among others. An Occupational Therapy student was able to enter the room to retrieve supplies, indicating that the room was accessible to individuals who should not have had access. Interviews with facility staff, including an LPN and a Licensed Nurse, confirmed that the central supply room was supposed to remain locked to prevent unauthorized access to medications and supplies. The Director of Nursing also verified that the room contained over-the-counter medications and wound care supplies and emphasized the importance of keeping the room locked to prevent residents and family members from accessing the medications. The facility's policy on the storage of medications and biologicals, revised in August 2023, mandates that all medications be securely stored in locked compartments, which was not adhered to in this instance.
Failure to Document Nutritional Assessment and Food Preferences
Penalty
Summary
The facility failed to complete a nutritional assessment, including food preferences, within 72 hours of admission for one of the sampled residents. Resident 2, who was admitted with diagnoses including lupus and mild kidney injury, did not have documented nutritional assessment or food preferences in their medical record. A physician's order indicated a regular diet with regular texture and thin liquid consistency, but there was no documentation of food preferences. The Dietary Director stated that dietary staff should meet with newly admitted residents within 24 hours to obtain food preferences, which should be documented in the medical record. However, a staff member from medical records confirmed that Resident 2's medical record lacked this documentation. The facility's policy required the Director of Food and Nutrition Services, Registered Dietician, or designee to visit residents within 72 hours of admission to obtain food and beverage preferences and complete the electronic nutrition assessment.
Failure to Implement Comprehensive Fall Management Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for the management of falls for one resident, identified as Resident 50, who had a history of cholecystectomy and dementia. The resident experienced a fall on March 10, 2024, and the care plan was revised on the same day to address the fall, including goals and interventions. However, the care plan lacked implementation for monitoring and managing the resident's fall risk. A physical therapy consultation was suggested in the care plan to assess the resident's strength and mobility, but this was not carried out. The Director of Rehabilitation explained that when a therapy screening is suggested, it should be scheduled and completed promptly, with documentation stored in the facility's electronic system and a hard copy in therapy. However, there was no record of a screening for this resident. The Director of Nursing confirmed that a screening was requested in the care plan dated March 10, 2024, and stated that it should occur within 3 to 5 business days, ideally within 72 hours. Despite this expectation, the screening and evaluation had not been conducted for seven weeks, indicating a failure to adhere to the facility's fall management policy, which requires monitoring and modifying care plans as necessary.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to ensure scheduled showers were provided to dependent residents, affecting one sampled resident and two unsampled residents. Resident 246, who was admitted with dementia and muscle weakness, was observed to have received only one shower since admission, with no sponge or bed baths provided during missed showers. The resident's care plan required substantial assistance for activities of daily living, including bathing, but there was no documented evidence of a completed shower or refusal on the scheduled date. Resident 215, admitted with dementia and fractures, also did not receive scheduled showers or bed baths on multiple occasions in November 2023. The resident's medical records lacked documentation of any refusal, and the Director of Staff Development confirmed the absence of records for the scheduled showers. The resident required substantial assistance for bathing, as indicated in the assessment, but the facility failed to provide the necessary care. Resident 213, who had hemiplegia and required maximal assistance with bathing, did not receive scheduled showers or baths on several dates in November and December 2023. The ADL flowsheet lacked documentation of showers or baths, and there was no record of refusal. The facility's policy required assistance for residents unable to perform activities of daily living, but the facility did not adhere to this policy, resulting in a deficiency in providing necessary hygiene care.
Inadequate Justification and Care for Urinary Catheter Use
Penalty
Summary
The facility failed to ensure appropriate care for a resident with a urinary catheter, leading to a deficiency. Resident 203 was admitted with a diagnosis of benign prostatic hyperplasia (BPH) without lower urinary tract symptoms and had an indwelling catheter. The resident was unable to explain the need for the catheter, and the medical record lacked documentation of a bladder training program or justification for the catheter's use. The Director of Nursing (DON) acknowledged that BPH alone was not a sufficient diagnosis for catheter placement and that the diagnosis should be associated with urinary retention. The facility's policy required a determined need and medical indication for catheter use, and residents with indwelling catheters should be assessed for removal as soon as possible. However, these protocols were not followed for Resident 203.
Failure to Adhere to Fluid Restriction for Dialysis-Dependent Resident
Penalty
Summary
The facility failed to adhere to a physician-ordered fluid restriction for a dialysis-dependent resident, identified as Resident 14, who was diagnosed with end-stage renal disease and other cardiac conditions. The physician's order specified a daily fluid restriction of 1000 ml, with specific allocations for meals and nursing shifts, and required documentation of the resident's fluid intake. However, observations revealed that Resident 14 had access to a water pitcher containing approximately 1000 ml, along with other beverages such as soda and smoothies, which exceeded the prescribed fluid limit. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and Certified Nursing Assistants (CNAs), indicated a lack of awareness and communication regarding Resident 14's fluid restriction. The CNAs were unaware of the fluid restriction and continued to provide a full water pitcher throughout the day. The LPN confirmed the presence of excess fluids at the resident's bedside and expressed concerns about the lack of monitoring and documentation of fluid intake. The facility's Registered Dietitian (RD) and the dialysis center's RD both confirmed the necessity of the fluid restriction due to the resident's significant fluid retention and risk of complications. The facility's policies required adherence to physician orders and monitoring of fluid intake for residents on dialysis. Despite these policies, the care plan for Resident 14 did not reflect the fluid restriction, and staff failed to monitor and document the resident's actual fluid consumption. The Director of Nursing (DON) acknowledged the need for care planning and education regarding the resident's non-compliance with fluid restrictions, which posed a risk of fluid overload.
Failure to Account for Narcotics in Controlled Drug Record
Penalty
Summary
The facility failed to properly account for narcotics signed out on the controlled drug record for a resident, which had the potential to delay pain management and increase the risk for harm. The resident, who had been admitted with conditions including hemiplegia and hemiparesis following a cerebral infarction, had a physician's order for Hydrocodone-Acetaminophen to be administered as needed for moderate pain. However, the facility could not locate the narcotic log for several months, and the available records showed discrepancies between the narcotic log and the Medication Administration Record (MAR), indicating that the medication was signed out but not documented as administered. Interviews with facility staff, including the Assistant Director of Nursing (ADON), a Licensed Practical Nurse (LPN), and the Director of Nursing (DON), revealed that the expected procedure was for nurses to document in the narcotic log every time a narcotic was pulled from stock and to reconcile this with the MAR. The facility's policy required maintaining a system for accounting controlled medications and conducting periodic reconciliations. However, the failure to maintain accurate records and reconcile the narcotic log with the MAR led to the deficiency identified by the surveyors.
Failure to Discontinue Contraindicated Medication
Penalty
Summary
The facility failed to ensure that a physician's order to discontinue a medication was completed for one of the sampled residents, leading to the potential for adverse effects and unnecessary medication administration. Resident 14, who was admitted with end-stage renal disease and dependence on renal dialysis, was prescribed Spironolactone, a medication contraindicated for individuals on dialysis. A pharmacist reviewed the resident's medication regimen and recommended discontinuing Spironolactone on July 23, 2024. The physician agreed with this recommendation and indicated that the medication would be discontinued on July 29, 2024. Despite the physician's agreement to discontinue the medication, the medication administration record showed that Spironolactone was still active, with the most recent dose given on August 8, 2024. An LPN confirmed that the resident was still receiving the medication. The Director of Nursing explained the process for pharmacist review and noted that the Unit Manager was responsible for ensuring that physician responses were documented and acted upon. However, the Spironolactone order was not discontinued as recommended, indicating a failure in the facility's process to prevent unnecessary medication administration.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a medication administration pass observation that revealed a 7.41% error rate. During the observation, 27 medication administration opportunities were noted, with two errors identified. One of the errors involved a resident who was prescribed Gabapentin 100 mg, two capsules to be taken three times a day for neuropathy, but was only administered one capsule. Additionally, the resident was supposed to receive Oxybutynin 5 mg, which was not administered, although it was documented as given in the Medication Administration Record (MAR). The resident involved had a medical history that included chronic kidney disease, acute kidney failure, and polyneuropathy. The Licensed Practical Nurse (LPN) responsible for the medication pass confirmed the errors, acknowledging that the correct dosage of Gabapentin and the Oxybutynin were not administered as per the physician's orders. The Director of Nursing (DON) indicated that nurses are expected to verify the five rights of medication administration, including the right dosage and medication, and to check the MAR and physician's orders before administering medications. The facility's policy on medication administration emphasizes the importance of adhering to physician orders to ensure safe and appropriate medication administration.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure proper labeling and dating of stored foods, as well as appropriate storage practices, which posed a potential risk to safety and health standards. During an observation on August 6, 2024, open bags of green beans, asparagus, and peppers & onion mix were found in the walk-in freezer without any indication of when they were opened. Additionally, a bottle of lemon juice, Jello packets, and canned pimentos in the dry storage area were missing received-on dates, and a milk substitute was stored in the reach-in cooler without a lid. The Dietary Manager acknowledged that these items should have been dated and properly stored. Further observations on August 7, 2024, revealed a jug of pink liquid in the reach-in cooler without a label or date, and employee drinks were improperly stored in the same cooler. Additionally, cookie dough ice cream was found in a container of cookie dough in the ice cream shop's reach-in freezer, with the Activity Director unable to explain how it got there. The facility's Food Safety document, reviewed on May 1, 2024, outlined proper food storage and labeling procedures, which were not followed in these instances.
Failure to Ensure Safe Discharge for Two Residents
Penalty
Summary
The facility failed to ensure a safe discharge for two unsampled residents, R214 and R219, which could have resulted in them being placed in inappropriate home settings without the necessary care. For Resident 214, the discharge process was inadequately documented. Although the discharge summary indicated that the resident was cleared for discharge to a group home with home health services, there was no evidence that a representative from the group home evaluated the resident, nor was there documentation of the resident's or family's agreement to the discharge plan. Additionally, the Case Manager and Director of Social Services were not involved in the discharge process, and the former Social Worker who handled the case was no longer employed at the facility. Similarly, for Resident 219, the discharge process lacked proper documentation and involvement of key personnel. The resident was discharged to a group home, but there was no record of the spouse's involvement in the discharge process or confirmation that the group home representative evaluated the resident. Furthermore, the resident's file did not contain the address of the group home or its name. The Case Manager and Director of Social Services were also not involved in this discharge, and the former Social Worker was no longer with the facility. The facility's discharge policy, which requires resident and representative involvement and documentation of referrals, was not adhered to in these cases.
Latest citations in Nevada
A resident with multiple medical conditions, including ESBL resistance and neuromuscular bladder dysfunction, was injured when a roommate pushed or slammed a bedside table toward their face during an argument about television volume, causing a cut lip and a loose tooth. The incident occurred in a shared room, involved resident-to-resident physical contact, and required assessment and law enforcement notification, demonstrating a failure to protect the resident from physical abuse.
An unauthorized male intruder repeatedly gained access to the facility through unsecured or inadequately controlled entry points, including following someone into the kitchen, bypassing the front lobby visitor kiosk, and entering through a window that was not fully locked. On one occasion he entered a resident’s room, identified himself as kitchen staff, and stole the resident’s cellphone containing personal identification and financial cards; on other occasions he stole personal items from staff, including a cellphone, wallet, and keys. Door alarms did not sound when he entered during at least one event, and staff initially considered the resident’s report possibly delusional before connecting it to prior and subsequent thefts and video evidence showing the same individual inside the building and on the grounds.
Multiple residents with psychiatric and behavioral histories physically assaulted other residents, including those with impaired cognition and significant medical conditions, resulting in documented injuries such as facial redness, bleeding, skin tears, abrasions, swelling, and periorbital discoloration. In separate episodes, one resident was slapped and nearly burned with a lit cigarette in a smoking area, another was pushed to the floor and kicked after entering a room, and two different roommates were punched on consecutive nights by the same hostile, non-redirectable resident. Facility leadership acknowledged a high behavior population, confirmed these events met the definition of willful infliction of injury and physical abuse, and reported that the aggressors had intact cognition, prior psychiatric hospitalizations, refusal of psychotropic medications, and a history that included homicidal ideation and threats with a weapon.
The facility failed to provide necessary behavioral health services, including trauma evaluations and meaningful interventions, for several residents involved in physical altercations and with significant psychiatric histories. After two residents were physically assaulted by roommates and sustained injuries, psychiatric providers were notified but did not document trauma-focused evaluations or address contributing behaviors such as wandering. Two other residents with schizophrenia, schizoaffective disorder, violent behavior, and documented noncompliance with psychotropic medications were involved in repeated aggressive incidents toward peers and staff, yet records showed only routine refusals of medication without evidence of effective, individualized behavioral interventions. The facility acknowledged a high-behavior population and a pattern of resident altercations, along with dissatisfaction with the psychiatric NP’s limited and delayed evaluations.
Failure to report resident-to-resident physical abuse: A resident with Alzheimer's disease was documented slapping another resident, and the other resident slapped back. The on-call manager was notified, but the incident was not reported to the SA. The DON later stated it was probably mutual combat and the MDS Coordinator, who was the DON at the time, confirmed physical abuse includes hitting and slapping and denied the incident was reported.
A resident with MS and polyneuropathy developed new occasional urinary incontinence after previously being continent, but the care plan did not include a focused care area or interventions to address the change. The resident reported not recalling staff prompting toileting at timed intervals, and the DON confirmed the care plan lacked urinary incontinence interventions and that the facility did not have a bladder training or retraining policy.
Failure to address new urinary incontinence: A resident with MS and polyneuropathy, previously continent of bladder, began having occasional urine incontinence but did not recall staff prompting toileting at timed intervals. The MDS later documented occasional bladder incontinence, yet the care plan had no focused interventions for the change in condition. The CNA was unaware of any bladder training/retraining program, and the DON confirmed the care plan lacked related interventions and the facility had no bladder training/retraining policy.
The facility failed to complete a required annual CNA performance review for one CNA, Employee #8, whose personnel record had no documented evaluation. The HR Director stated CNA evaluations were done each year on Oct. 1 to review the prior year and confirmed this CNA was not reviewed 12 months after starting at the facility. The Facility Assessment stated weaknesses identified in CNA performance reviews and annual competency assessments would be addressed through in-service training.
Facility Assessment did not match actual night shift staffing. The assessment stated Harmony Manor and Quail Corner each required an LPN on nights, with consistent staffing prioritized in the memory care unit, but the April schedule showed both units sharing one licensed nurse on multiple nights. The DON confirmed one nurse was responsible for all 32 residents on those nights and acknowledged the assessment needed to reflect the staffing schedule.
Unsanitary Kitchen Floor Drain: A kitchen floor drain was observed with a buildup of debris and grime, and the Kitchen Mgr confirmed it was dirty and could spread contamination. The Mgr stated floor cleaning was the responsibility of Maintenance, and the Maint Mgr later confirmed the drain had not been recently cleaned and was not sanitary. The facility policy required strict sanitary conditions in Dietary and Nutrition to prevent food contamination and growth of disease-producing organisms.
Failure to Protect Resident From Roommate’s Physical Abuse During Altercation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a roommate. The resident was admitted with diagnoses including local infection of the skin and subcutaneous tissue, ESBL resistance, and neuromuscular dysfunction of the bladder. On the evening of 04/10/2026, while in a shared room, the roommate pushed or slammed a bedside table toward the resident during a dispute about the television volume being too loud. The bedside table struck the resident in the face, resulting in a bleeding lip and a loose tooth. The resident reported that the roommate became angry about the television volume and then pushed the bedside table toward their face. Following the incident, the resident was observed with blood on the face and lip, and a loose tooth was noted. The resident declined transfer to the hospital. Law enforcement was contacted, and both residents provided statements to the responding officer, with the injured resident declining to press charges. The roommate later stated that the bedside table had been positioned on the side of the bed and that they were pushing it back toward the other side, claiming they were simply returning the bedside table to its proper place. The facility’s failure to prevent this resident-to-resident physical altercation and resulting injury constituted a failure to protect the resident from physical abuse.
Unauthorized Intruder Repeatedly Accesses Facility and Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment for residents and staff when an unauthorized male intruder repeatedly gained access to the building and entered resident and staff areas, including a resident room. One resident, identified as R94, had been admitted with anxiety disorder, major depressive disorder, and left knee pain, and was alert and oriented at the time of the incident. Around 5:00 AM in December 2025, R94 observed an unknown man enter the resident’s room, state that he was kitchen staff checking the table for breakfast, and then take the resident’s cellphone, which contained a driver’s license, debit card, health insurance card, and bus card. R94 reported that the door alarms did not sound when the man entered the facility and that the resident typically heard alarms when someone entered without using the correct code. After the theft, there were two unauthorized charges on the resident’s debit card. Staff interviews revealed that this was not an isolated security breach. An LPN reported that in December 2025, R94’s report of a man entering the room and taking the cellphone was initially considered possibly delusional due to the resident’s history of seeing a person, but during the same IDT discussion another nurse reported that the day before R94’s report, a stranger had entered the kitchen and stolen a dietary staff member’s iPhone around 5:30 PM. Security camera footage showed the same man entering through a kitchen door by following someone from behind, indicating that he was able to bypass normal access controls. The same individual was later seen twice in the parking lot, and staff contacted police on those occasions. A CNA also recalled interacting with a man who claimed he was there to pick up belongings of a discharged resident and asked for the Wi‑Fi password, which the CNA provided; during the subsequent investigation, this man was identified as the same individual seen on video breaking into the building. The Administrator’s review of the January 24–25, 2026 incident documented that during a night shift, an unauthorized individual gained access by exploiting a window on the south side of the building that was not fully seated in the locked position, allowing him to shimmy the frame open and enter an unoccupied case management office. From there, he exited into the hallway, went to the nurse station, and took a nurse’s wallet and keys. As he attempted to exit through a west door, the door alarm sounded, but he was able to reach a vehicle and flee before staff arrived. The Administrator also confirmed a prior December 24, 2025 security breach in which an unauthorized male bypassed the front lobby visitor kiosk, entered the facility, and went into R94’s room, where he removed the resident’s cellphone and attached personal items from the bedside. Investigation of that December incident showed the individual was not an authorized visitor, family member, or vendor, and that he had been able to enter the building and a resident room without being stopped at the kiosk or by staff. The DON stated that R94’s report was handled as a grievance and resolved, but there were no IDT notes related to the incident, and the Administrator was not aware of the earlier kitchen theft when first discussing the December event.
Failure to Prevent Resident-on-Resident Physical Abuse in High-Behavior Population
Penalty
Summary
The facility failed to protect residents from physical abuse when multiple residents with known psychiatric and behavioral histories physically assaulted other residents on several occasions. In the first incident, one resident with fibromyalgia and an unspecified intracranial injury reported being slapped, cursed at, and nearly struck in the face with a lit cigarette by another resident in the smoking area, resulting in redness to the mandible area and involvement of law enforcement. The aggressor stated the victim was being annoying and deserved the assault. In a separate incident, a resident with moderately impaired cognition and no documented aggressive or wandering behaviors was pushed to the floor and kicked by another cognitively intact resident with schizophrenia and paranoid personality disorder after entering that resident’s room, causing a bleeding nose, a skin tear to the left forearm, and redness of the left forehead. Additional incidents involved a resident with moderately impaired cognition who reported being punched by a roommate, resulting in mild forehead swelling, and another resident with chronic obstructive pulmonary disease, heart failure, and schizoaffective disorder who was punched by the same aggressor after being moved into the room, sustaining discoloration around the left eye socket, a nose bridge abrasion, and a skin tear to the left forehead. Documentation showed that the aggressive resident was screaming violently, hostile, physically aggressive, and non-redirectable toward both residents and staff. The wound care team’s head-to-toe assessments confirmed the physical injuries sustained by the assaulted residents. Interviews with the DON, SSD, and DSD confirmed that these incidents met the facility’s own definition of willful infliction of injury and were classified as physical abuse. The DON stated that the aggressors had intact cognition, histories of inpatient psychiatric stays, and, in one case, a history of homicidal ideation and prior psychiatric hospitalization for chasing a person with a knife and threatening police. Facility leadership acknowledged a high behavioral population, an average of 45 residents with behavioral issues, and identified a pattern of resident altercations and physical abuse. They reported that the aggressors were refusing psychotropic medications and that concerns about psychiatric support, admission screening, and limitations on use of IM psychotropics had been communicated to the psychiatric provider and medical director, but these issues remained unresolved at the time of the incidents.
Failure to Provide Trauma Evaluations and Effective Behavioral Health Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services, including trauma evaluations, following resident-to-resident physical abuse incidents. One resident with psychosis, schizophrenia, and major depressive disorder was found on the floor with a bleeding nose, a skin tear, and forehead redness after being pushed and kicked by another resident. A psychiatry progress note documented that the psychiatric NP saw the resident per staff request, but the record lacked documentation that the altercation or physical abuse incident was discussed or that the resident’s newly identified wandering behavior, which led to the altercation, was addressed. Another resident with COPD, heart failure, and schizoaffective disorder was punched by a roommate, resulting in discoloration around the eye, a nose bridge abrasion, and a forehead skin tear. Although the care plan for emotional distress included a psychiatry evaluation and the NP was informed of the incident, there was no documented evidence that a psychiatric trauma evaluation was completed. The facility also failed to implement meaningful behavioral health interventions for residents with psychiatric histories, aggressive behaviors, and refusal of psychotropic medications. One resident with schizophrenia and paranoid personality disorder, intact cognition, and a history of violent behavior and homicidal ideation, including chasing a person with a knife and threatening police, was involved in multiple physical altercations. This resident punched another resident in the smoking area and later admitted to pushing and kicking a different resident who entered the room. The care plan identified behavioral problems such as irritability, anger, violent behavior, homicidal ideations, mood swings, and a tendency to push and kick other residents, with interventions including attempts to identify underlying causes. However, the medical record showed the resident routinely refused medications, and there was no documentation of effective, meaningful interventions addressing this ongoing refusal and associated behaviors. Another resident with neuroleptic-induced Parkinsonism, schizoaffective bipolar type, and psychosis, recently transferred from a psychiatric hospital after an exacerbation of schizophrenia symptoms and noncompliance with psychotropic medications, was also involved in a physical altercation. Progress notes documented that this resident punched a roommate, was screaming violently, hostile, physically aggressive, and non-redirectable toward residents and staff. A social services note indicated that when staff attempted to discuss the altercation, the resident became agitated, screamed, yelled, and used inappropriate language, preventing further information gathering. A refusal of treatment form showed the resident had declined medications after being informed that refusal could affect mood stabilization and worsen behaviors. Despite the facility’s acknowledgment of a high-behavior population and multiple resident altercations, the report describes a pattern of inadequate psychiatric support and lack of thorough evaluations and timely, effective behavioral interventions for these residents.
Failure to Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure an incident of resident-to-resident physical abuse was reported to the State Agency for 1 of 12 sampled residents. Resident #10, who was admitted with diagnoses including Alzheimer's disease and episodic tension-type headache, was documented in a nursing progress note as having been seen by a CNA slapping another resident, after which the other resident slapped Resident #10 back. The on-call manager was notified and directed staff to keep the residents apart and maintain them in eyesight if together. A physician progress note later documented that Resident #10 had been involved in a behavioral disturbance in which a heated exchange led to physical aggression between the two residents, with each resident physically striking the other. The DON stated the incident would probably not be considered resident-to-resident abuse because it was mutual combat and said the DON did not know whether either resident had been assessed for pain, injury, or mental anguish. The MDS Coordinator, who was the DON at the time of the incident, confirmed physical abuse includes hitting and slapping, denied being aware of the incident at the time, and denied that it was reported to the SA.
Care Plan Missing Interventions for New Urinary Incontinence
Penalty
Summary
The facility failed to develop a care plan with interventions to assist Resident #24 in maintaining continence after the resident, who had previously been continent, began experiencing occasional urinary incontinence. Resident #24 was admitted and later readmitted with diagnoses including multiple sclerosis and unspecified polyneuropathy. On 04/20/2026, the resident stated they had recently started having occasional urinary incontinence but could still get to the bathroom once they realized they were urinating, and the resident could not recall staff prompting them to toilet at timed intervals. An MDS assessment dated 07/07/2025 documented the resident was always continent of bladder, while an MDS assessment dated 04/06/2026 documented the resident was occasionally incontinent of bladder. The care plan did not include a focused care area or interventions related to the resident’s new urinary incontinence. On 04/22/2026, the DON stated the resident had become increasingly incontinent over the last several months and believed it was related to the resident’s multiple sclerosis. The DON also stated the facility could try offering assistance with a toileting schedule and confirmed the care plan did not include a care area or interventions related to the resident’s urinary incontinence, and that the facility did not have a policy for a bladder training or retraining program.
Failure to Address New Urinary Incontinence
Penalty
Summary
The facility failed to ensure a previously continent resident received assistance or interventions to maintain or improve urinary continence after the resident began experiencing occasional urinary incontinence. Resident #24 was admitted with diagnoses including multiple sclerosis and unspecified polyneuropathy. The resident stated that the resident had recently started having occasional urinary incontinence but could still reach the bathroom once the resident realized the resident was urinating, and the resident could not recall staff prompting bathroom use at timed intervals. Record review showed an MDS dated 07/07/2025 documented the resident was always continent of bladder, while an MDS dated 04/06/2026 documented the resident was occasionally incontinent of bladder. The care plan did not include a focused care area or interventions related to the new urinary incontinence. The CNA stated the resident had begun experiencing incontinence several months earlier and was not aware of any bladder training or retraining program, while the DON stated the resident had become increasingly incontinent over the last several months and that the facility could try a toileting schedule; the DON also confirmed the care plan lacked interventions related to the resident's new urinary incontinence and that the facility did not have a policy for a bladder training or retraining program.
Missing Annual CNA Performance Review
Penalty
Summary
The facility failed to ensure a nurse aide performance review was completed at least once every 12 months and that areas of weakness were identified and addressed for 1 of 2 sampled CNAs, Employee #8. Employee #8 was hired as a CNA on 10/21/2024, and the personnel record lacked documented evidence of a nurse aide performance evaluation. During interview on 04/22/2026, the HR Director stated CNA performance evaluations were completed every year on October 1st to review the prior year and explained that, because of the date of hire, Employee #8 was not reviewed for performance. The HR Director confirmed Employee #8's nurse aide performance review was not completed 12 months after starting at the facility. The Facility Assessment, updated 03/2026, documented that areas of weakness identified in nurse aide performance reviews and annual competency assessments would be addressed through in-service training.
Facility Assessment Did Not Match Night Shift Staffing
Penalty
Summary
The facility failed to ensure its Facility Assessment accurately reflected current staffing needs. The Facility Assessment, updated 03/26/2026, stated the staffing plan included one licensed nurse on night shift for Harmony Manor and one licensed nurse on night shift for Quail Corner, and that consistent staffing would be prioritized in the memory care unit, with staffing levels not adjusted for low census or low acuity so resident needs would be met during call-ins and other staffing shortages. However, the April 2026 staffing schedule showed Quail Corner and Harmony Manor sharing a licensed nurse during night shift on multiple nights. During an interview on 04/24/2026, the DON stated that on Saturday, Sunday, Monday, and Tuesday nights, both units shared one licensed nurse during night shift, and that the nurse was responsible for all 32 residents in the facility. The DON confirmed the Facility Assessment indicated each unit required a licensed nurse during night shift and stated the Facility Assessment needed to be updated to reflect the staffing schedule.
Unsanitary Kitchen Floor Drain
Penalty
Summary
The facility failed to ensure staff maintained sanitary floor drains in the kitchen. On 04/20/2026 at approximately 10:45 AM, a kitchen floor drain was observed with a buildup of debris and grime. At approximately 10:50 AM the same day, the Kitchen Manager confirmed the drain had buildup of grime and acknowledged the potential spread of contamination, and stated that cleaning of the floor was the responsibility of the Maintenance Department. On 04/23/2026 at approximately 9:15 AM, the Maintenance Manager confirmed the kitchen floor drain had not been recently cleaned, was not sanitary, and acknowledged the potential spread of contamination. The facility policy titled, Maintenance of Strict Sanitary Conditions, dated 07/12/2022 and reviewed 07/08/2024, stated that maintaining strict sanitary conditions was of paramount importance in the Dietary and Nutrition Departments to eliminate food contamination and prevent growth of disease producing organisms, and to ensure maximum cleanliness and sanitation in the department.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
